If your insurance says they won't cover something, is there any way around it?

Question

Do appeals really work? Will a note from the doc saying it's "medically neccessary" help?? Thanks!

Adding more details to clarify.. my son (2 years old) has been diagnosed with an expressive language disorder. He doesn't talk at all. They want him to have speech therapy 1x per week for a year. In my summary of benefits it says it's covered with a copay each time.. but then on some other form it says therapy is not covered unless from an injury. They are saying the second thing wins out over my summary of benefits.

Answer 1

Generally speaking, the policy does overrule the language on the summary of benefits (which is more of a brochure, not a contract) but they typically do not contradict unless an error has been made. Who created your summary of benefits? If it was created by your employer or your employer's agent, then you might have a legal argument that it was a written promise - and might have some leg to stand on to have them pay your claim out of their pocket, but it's a slim chance unless you were not provided access to a policy or the summary doesn't tell you to refer to the policy as a ruling document.

As far as the appeal goes, I would write a letter to the insurer asking for the claim to be reconsidered in light of the fact that it is deemed medically neccessary and that your summary of benefits states that this is covered (if it was generated by the insurer). The insurer doesn't have to honor anything created by your employer or your employer's agent, if it contradicts the policy.

Appeals do work - you have to try. Typically, you get two appeals and then maybe a mediation - depends upon the insurer.

Good luck!

Answer 2

"Medically necessary" means nothing to an insurance company. You are covered for what your contract offers and nothing more or less.

Given the high cost of healthcare in today's market, not all insurance policies cover all procedures, medically necessary or not.

You may appeal, but you won't get far unless the procedures and expenses were somehow misstated by the healthcare providers.

Answer 3

The option to appeal is your right. In this circumstance, its probably pointless to appeal. If the speech has to be restorative in order to be covered, you're basically out of luck. Try looking into speech programs available through the school district your live in & the state. good luck

Answer 4

Yes, appeals really work, if the situation warrants it. You're NOT going to get cosmetic surgery covered, even if you appeal, using the "mental distress" or "mental health" appeal. But if it's not really cosmetic - ie, if you've had a radical mastectomy and it's reconstructive, then an appeal can help in that situation.

Regarding the doctor's note - it helps to have two opinions, or more, detailed, explaining WHY it's necessary.

Answer 5

hard to say--not enough information. however, insurance is a contract and what the contract says usually governs unless it is unenforceable language where written because of statute or perhaps some case law. if you are talking about health insurance and something that was elective or ordinarily considered elective then medically necessary can possibly change the situation but i suppose that they could have it reviewed by a physician of their choice which may refute. depends. i guess it can't hurt to ask.

Answer 6

Read your policy to see if you have coverage then file an appeal. Not everything medically necessary is covered on all policies like you could have no coverage for maternity and they won't pay for you to have a baby even if it is medically necessary. You doctor may have miscoded the request for coverage information.